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<a name="PageN1"></a>
<table width="718" align="center" border="0" cellspacing="0" cellpadding="0">
<tr style="height: 1px"><td width="8"/><td width="4"/><td width="2"/><td width="68"/><td width="1"/><td width="1"/><td width="3"/><td width="11"/><td width="91"/><td width="7"/><td width="23"/><td width="4"/><td width="12"/><td width="41"/><td width="23"/><td width="5"/><td width="1"/><td width="62"/><td width="31"/><td width="26"/><td width="51"/><td width="8"/><td width="9"/><td width="8"/><td width="59"/><td width="13"/><td width="4"/><td width="64"/><td width="78"/><td width="1"/></tr>
<tr style="height:26px">
<td colspan="30" class="s0">中心报销待遇核定表</td>
</tr>
<tr style="height:22px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:15px">
<td/><td colspan="14" class="s1">经办机构：银川市社<br>会保险事业管理中心</td><td/><td/><td colspan="4" class="s1">结算日期：2020-12-3</td><td/><td colspan="7" class="s1">结算流水号:20201203111016315874</td><td/>
</tr>
<tr style="height:5px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="6" class="s2">个人编号</td><td class="s17">2001623839</td><td colspan="5" class="s2">社会保障号</td><td colspan="6" class="s18">640103193706081517</td><td colspan="3" class="s19">姓名</td><td colspan="3" class="s18">陈兆斌</td><td colspan="2" class="s19">性别</td><td colspan="2" class="s18">男</td>
</tr>
<tr style="height:1px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="6" class="s2">开户银行</td><td class="s17">自管账户</td><td colspan="5" class="s2">银行账号</td><td colspan="6" class="s18">2001623839</td><td colspan="3" class="s19">险种</td><td colspan="7" class="s18">职工基本<br>医疗保险</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="6" class="s2">医疗类别</td><td class="s17">门诊大病</td><td colspan="5" class="s2">人员类别</td><td colspan="6" class="s18">异地备案<br>就医的非灵活就业人员</td><td colspan="3" class="s19">人员状态</td><td colspan="7" class="s18">退休</td>
</tr>
<tr style="height:1px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="6" class="s5">住院号</td><td class="s17">1</td><td colspan="5" class="s5">发票号</td><td colspan="6" class="s20">1</td><td colspan="3" class="s21">入院日期</td><td colspan="3" class="s22">2020-03-17</td><td colspan="2" class="s21">出院日期</td><td colspan="2" class="s22">2020-09-11</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="6" class="s8">住院天数</td><td class="s17">1</td><td colspan="5" class="s8">医疗机构名称</td><td colspan="12" class="s23">六安市人<br>民医院</td><td colspan="2" class="s24">机构等级</td><td colspan="2" class="s23">三级甲等</td>
</tr>
<tr style="height:1px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:33px">
<td/><td/><td colspan="6" class="s5">门诊大病名称</td><td colspan="12" class="s20">慢性阻塞<br>性肺疾病,老年性痴呆</td><td colspan="4" class="s21">出院诊断</td><td colspan="6" class="s20">慢性阻塞<br>性肺病</td>
</tr>
<tr style="height:33px">
<td/><td/><td colspan="6" class="s25">备注</td><td colspan="22" class="s26" style="font-size:1px">&nbsp;</td>
</tr>
<tr style="height:7px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="16" class="s10">费用构成</td><td colspan="12" class="s27">统筹支出构成</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">甲类药品</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">费用总额</td><td colspan="3" class="s30">3014.56</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">乙类药品</td><td colspan="7" class="s28">3014.56</td><td colspan="9" class="s29">医保起付额</td><td colspan="3" class="s30">500.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">丙类药品</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">全自费</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">丁类药品</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s31">超限价耗材</td><td colspan="3" class="s28">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">诊疗范围内(A类)</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">基本统筹支付</td><td colspan="3" class="s30">1772.87</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">诊疗范围内(B类)</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">大额支付</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">诊疗范围内(C类)</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">补助支付</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">诊疗范围内(定额)</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">医院支付</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">诊疗范围外</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">个人账户支付</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">段1耗材</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">个人现金支付</td><td colspan="3" class="s30">1241.69</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">段2耗材</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">封顶线自付</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">段3耗材</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">基本统筹自付</td><td colspan="3" class="s30">741.69</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">段4耗材</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">补助自付</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">限价耗材</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">大额自付</td><td colspan="3" class="s30">0.00</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">非医保耗材</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">医保支付</td><td colspan="3" class="s30">1772.87</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">定额服务</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29">个人支付</td><td colspan="3" class="s30">1241.69</td>
</tr>
<tr style="height:18px">
<td/><td/><td colspan="9" class="s25">定额药品</td><td colspan="7" class="s28">0.00</td><td colspan="9" class="s29" style="font-size:1px">&nbsp;</td><td colspan="3" class="s32" style="font-size:1px">&nbsp;</td>
</tr>
<tr style="height:7px">
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<tr style="height:18px">
<td/><td/><td colspan="9" class="s6">医保支付合计(大写) ：</td><td colspan="16" class="s20">壹仟柒佰柒拾贰元捌角柒分</td><td colspan="3" class="s16">1772.87</td>
</tr>
<tr style="height:12px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:15px">
<td/><td/><td/><td class="s15">经办人：</td><td/><td colspan="5" class="s14">冯丽芝</td><td/><td/><td/><td colspan="3" class="s15">审核人：</td><td colspan="3" class="s14">审</td><td/><td/><td/><td colspan="3" class="s15">复核人：</td><td/><td/><td/><td/><td/>
</tr>
<tr style="height:4px">
<td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:1px">
<td/><td/><td/><td/><td/><td/><td colspan="6" rowspan="2" class="s14">2020-12-3</td><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:14px">
<td/><td/><td colspan="4" rowspan="2" class="s15">经办日期：</td><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
<tr style="height:1px">
<td/><td/><td class="s15" style="font-size:1px">&nbsp;</td><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/><td/>
</tr>
</table>
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